HPI: 41-yr-old female with complaint of right sided sciatic type pain since Jan 9, 2013.
Dull background lower backache on and off for the month preceding this current episode of rt-sided pain.
H/o lifting heavy grocery bags preceding this current episode.

Nature of pain: Sharp, stabbing, beginning in the rt SI joint, spreading in a fan shaped fashion all over the right buttock, posterior and anteriorly, as if going into the labial/vulval region.
Radiation down the entire right thigh (articularly posterolaterally) and into the lateral aspect of the right leg and ankle, both dorsum and sole.

Aggravating factors: Drawing legs up to abdomen aggravated the thigh and leg pain plus numbness in the leg and thigh. Also aggravated by sitting to standing and supine to sitting transfers.

Relieving factors:
Lying down flat
Painkillers
Hot fomentation
Started homeopathic medication on Jan 9, 2013 with noticeable improvement in symptoms.

Past History:
1.     1st episode of prolapsed intervertebral disc (L5-S1) in Nov 1991—treated conservatively. Episode occurred after lifting filled bucket.

2.     2nd episode of the same in July 1992 following fall.

3.     3rd episode in 2001—following fall in bathroom.

4.     Known case of C4-C7 spondylosis…with occasional exacerbations including numbness and pain radiating down the left neck and into left palm and fingers waking me up at night….requiring me to shake hand and do the cervical exercises in order to fall back to sleep.

Treatment received---2nd and 3rd both episodes treated with homeopathy following failure of conservative allopathic approach. Complete bed rest for 9 months during second episode. Resumed normal activity after this, including completion of MBBS and normal vaginal delivery at full term.

There was a dull background lower backache present before the current episode. Not incapacitating, and I was able to carry on with my normal routine activities. I did however feel extremely drained out on a daily basis….at the end of the day….and in retrospect, one recalls that my lower limbs (particularly the ankles and feet) felt kind of “limp” and felt better with someone applying pressure….as in massaging the calves and legs.

Started physiotherapy with short wave diathermy on Feb 9, 2013 followed by gentle stretching exercises.

Recently, over the past week or so…I have noted…my back pain and the typical sciatic symptoms with numbness, pain, heaviness in back and legs, ankles are all gone....but a new development over the past several days is...

I feel my muscles dont have enough tone. Particularly several hours after the routine stretching exercises i get a kind of "looseness" sensation in the muscles, say a trembling, and when i move my limbs...like say abduct my leg at the hip and bring it back...i feel the movement is not smooth...but a bit jerky...one cannot even call it a clear cut fasciculation or jerks or twitch as such....it is not visible...only i feel it...

There is a kind of achy pain in the muscles (the kinds one gets when one does any kind of unaccustomed exercise). The muscles used to feel stiff and hard…but that is not so any longer.
Even before this episode...i used to take long 45 min walks everyday...but i wasnt doing any stretching for any part of the body Therefore, my physiotherapist says that it is the poor tone of the muscles causing this and it will take time for them to recover...dunno...but this seems to be constant..a kind of weakness....flaccidness...dunno how to describe it...

I have no bladder/bowel complaints....just a kind of non-smooth muscle movements....I used to get cramps in the calves and groin...those are now gone...but my right leg feels like its still “hard” and doesnt synchronise well with the left leg while walking...so I have to stop…exercise it a bit and resume walking….or I have to sit for a while and resume walking normally.

of late, I feel the same jerkiness/trembling/nonsmooth muscle movements in both arms…and forearms. I don’t know if this could be attributed to the fact that I am doing back extension exercise where the whole body weight rests on the arms….and if that action is causing my already poorly toned muscles to feel fatigue/strain.

My physiotherapist feels that my symptoms are due to my muscles being weak and nontoned...so the bed rest, plus now the stretches that are making them work are leading to the muscle fatigue which can explain these symptoms...
Personal habits

1.     vegetarian—no eggs, meat, fish. But I have plenty of yoghurt on a daily basis and have for the past 40 years!
2.     Sedentary desk job…but active in that I used to walk regularly for 45 min on a daily basis, plus all household chores.

Investigations:

1.     vit D3—level low at 6.78
2.     vit B12---level of 236
3.     serum calcium—8.6

4.     MRI Scan of LS Spine: Performed on Jan 15, 2013

Findings: Loss of normal lumbar lordosis is seen
Transitional vertebra noted at lumbosacral junction with presence of an unfused first sacral vertebra and a well-formed S1-S2 disc
Vertebral bodies otherwise reveal normal signal intensity without any evidence of a focal lesion.
Marginal osteophytes are noted.

The L5-S1 disc is degenerated and shows mild diffuse posterior bulging with a capsular break indenting the thecal sac and both L5 nerve roots.

A small posterocentral protrusion of S1-S2 disc is noted indenting thecal sac.

Rest of the discs show no significant bulging or herniation.

Facetal arthropathy is noted at L4-L5 and L5-S1 levels.

Lower end of the spinal cord, cauda equina and filum terminale appear normal.

Prevertebral soft tissues and vascular structures appear normal.

Impression:

1.     A transitional vertebra noted at lumbosacral junction with presence of an unfused first sacral vertebra and a well-formed S1-S2 disc
2.     Mild diffuse posterior bulging of L5-S1 disc with a capsular break indenting the thecal sac and both L5 nerve roots.
3.     A small posterocentral protrusion of S1-S2 disc is noted indenting thecal sac.
4.     Facetal arthropathy is noted at L4-L5 and L5-S1 levels.



Current Medications:

1.     Vit B12- one daily
2.     Vit D3---60,000 IU once a week (completed 4 weeks already….and will complete for 8 weeks, following which have been advised to take 2000IU daily as maintenance)
3.     Calcium 500 mg daily
I am trying to remain as mobile as possible....trying to walk around...sit and work....but is it ok to continue to walk (slowly of course) and not go and lie down EVEN IF AND WHEN I GET PAIN after a period of activity like say sitting or walking for say half hour at a stretch? The reason i ask this is....I dont wish to continue doing something that might cause more damage to recovering tissues (nerves and muscles)...so should I take that pain as a signal that it is time to rest? OR....should i consider that a little pain will come on from time to time...and it must not make me immediately go and lie down...?

I did get a neurological consultation yesterday. My systemic exam is normal. On detailed neuro testing....my sensory is fine, motor is fine, reflexes all good, power is good, coordination is fine (i was able to do the finger-nose, heel-shin, Romber'gs, tandem walk...everything fine), heel and toe walk is fine....in short...the neurologist said there is NO NEUROLOGICAL DEFICIT on testing.

His line of thinking is...

1. There is poor muscle tone...for whatever reason....and so that must be improved with supplements plus physiotherapy.

2. Anxiety leading to the tremulousness and shakiness i feel.

Here...I differ in his opinion. I am feeling anxious BECAUSE OF THESE SYMPTOMS.....but he feels probably anxiety is precipitating these symptoms. I have noted these symptoms only recently...in the past month or so...and that too only after this episode of slipped discs, subsequent bed rest and the physio exercises that i started.

The medicines on board now are...

1. Vit D--0000 IU for 8 weeks....then once a month for 6 months
2. Meganeuron---once a day
3. Osteobon Plus---1 tab bid
4. Any multivitamin

He's asked me to see him in 2 months for followup.

My queries--

I still dont have an answer for the sense of shakiness and tremulousness i get in my upper limbs (its proximal...and not distal like one would see in the typical parkinsonian symptoms). There is a sense of weakness, fatigue, flabbiness, flaccidity (dont know how best to convey that feeling) in the arms, and hands...grip strength is normal..no dropping of things.

2. i get a sinking sensation at times...overall in my body...at which time i feel palpitations...throbbing at the base of the head, and i have to lie down....rest...and then this passes off after a while...though the weakness, shakiness in the limbs doesnt...that remains at a background baseline level.

3. At 42 years, I am getting my menstrual period normally...regularly. Menarche was at 10.5 years. Could this be the premenopausal stage and symptoms? I spoke to a gynec friend...and she doesnt feel this is related to that....coz my periods are regular, and i dont have the emotional/mental changes one would expect in this scenario. No skin changes, no vaginal dryness etc.

4. I dont know if we're looking at some connective tissue disorder...something like fibromyalgia,...some muscle issue that we're missing? What further testing/consultation can i undergo to arrive at a definitive diagnosis?

5. Could we be looking at something cardiac leading to such symptoms?

I am honestly really troubled by this shakiness, this sense of sinking.....its something I wish to end ASAP....Could you please speak with any neuro/endo/internal medicine or whatever specialty u deem appropriate to get me some answer to this? Please help me!